Medicare and Rehab Treatment- What You Need to Know

If you’re looking into rehabilitation services and trying to figure out your insurance coverage, the complexity of it all can be a bit overwhelming.

Whether it’s short-term physical therapy or extended stays in a skilled nursing facility, it’s important to know what Medicare covers, what it doesn’t, and how to prepare for any out-of-pocket expenses.

With Medicare’s different parts covering specific aspects of care, understanding each section, such as Medicare Plan B coverage, is key. For example, Plan B is different from Part B which can cause confusion. Medicare Part B is from the federal government and helps cover outpatient services. Medicare Plan B is one of the 10 standardized Medigap plans that helps pay secondary to Medicare.

Knowing the ins and outs can make a significant difference in managing costs. Let’s break it down into manageable pieces so you know what to expect when considering rehab treatment under Medicare.

What Exactly is Rehab?

Rehabilitation, in medical terms, is aimed at helping someone recover from an injury, surgery, illness, or severe medical event like a stroke. Rehab can involve physical therapy, occupational therapy, speech-language therapy, or even mental health support. Rehab services can take place in a variety of settings, and help people improve or regain the functions they need for daily life.

Medicare Part A: Inpatient Rehab Coverage

Medicare Part A covers inpatient care, such as hospital stays, skilled nursing facilities (SNFs), and some home health care. Part A is your starting point if you need rehabilitation in a hospital or a skilled nursing facility.

Once you meet these qualifications, Medicare covers your first 20 days in full for rehab in a skilled nursing facility. From day 21 to day 100, you’ll have a daily copayment. After day 100, you’ll be responsible for all costs.

Keep in mind that Part A does not cover care in a nursing home if the care is primarily custodial, meaning help with daily activities like eating, bathing, or dressing.

Medicare Part B: Outpatient Rehab Coverage

For rehab services provided outside of a hospital or skilled nursing facility, Medicare Part B steps in. This includes outpatient physical therapy, occupational therapy, and speech-language pathology services.

Part B covers medically necessary rehabilitation services, but you’ll be responsible for paying 20% of the Medicare-approved amount after meeting your annual Part B deductible ($240 in 2024). If you need ongoing rehab after a hospital stay or injury but don’t require inpatient care, Medicare will help cover the costs, but not all of them.

A Medicare Advantage or Medigap plan can help with these remaining costs. There’s no cap on how much rehab Part B will cover as long as it’s deemed medically necessary. Still, your doctor or therapist may need to provide detailed documentation justifying the continued treatment.

Home Health Rehab: Another Option

Medicare may also cover rehabilitation services through home health care. This can be an excellent option for people who are homebound but still need ongoing therapy.

Medicare can help cover the home health services if you meet the required qualifications. Remember, if you only need custodial care (like help with bathing or getting dressed), Medicare won’t cover it.

What Medicare Won’t Cover

While Medicare provides good coverage for rehab services, it’s important to be aware of the gaps. For example, Medicare does not cover:

• Long-term care in nursing homes when the primary need is custodial care (i.e., help with daily living activities).
• Private rooms or amenities beyond what’s medically necessary.
• Rehabilitation for conditions not deemed medically necessary by your healthcare provider.

Additionally, after the first 20 days in a skilled nursing facility, you’re responsible for a copay for days 21-100 and then 100% of the cost after day 100 if you continue to need care. These costs are why you may want to look into supplemental options to help with these expenses.

Preparing for Costs

Even with Medicare’s coverage, rehab treatment can still involve out-of-pocket costs. These could be deductibles, copayments, and coinsurance, especially for extended stays or repeated therapy sessions.

Medigap (Medicare Supplement) plans can help cover some out-of-pocket costs, such as the remaining Part B coinsurance.

Medicare Advantage (also referred to as Part C) plans can also provide coverage for rehab services, but each plan is different in terms of costs, networks, and benefits. You’ll want to review your plan carefully to know what’s covered and how much to expect your cost-sharing to be.

If you don’t have additional coverage, it may be worth exploring whether adding one could help reduce financial burden.

Being Proactive

Rehab treatment is often a critical step in recovering from a serious medical event. While Medicare provides substantial coverage, there are still some gaps and limitations to be aware of and plan around.

Once you know how Medicare works, you can plan appropriately for the care you need. Be proactive about checking what is covered, and don’t hesitate to ask your doctor or Medicare directly if you have any questions or need any clarity. Knowing the ins and outs of your coverage can help you focus on what matters most—your recovery.